Copy this page onto a blank document. Write in your answers to each question. SAVE
your answers. Most of this information can go directly onto a provider organization application.

Participating in this exercise will help prepare you in the process of getting
a service dog. Some of these questions will be asked by the source of your dog. Having the answers ready will
make the process go more smoothly. Also, you will begin to think about the changes and adjustments you will need to
make in having a service dog.

Sample Application

PART ONE: PERSONAL INFORMATION

Your Full Name:

What name do you prefer to be called?

Your Street Address:

Your Mailing Address:

Your City:

Your State:

Your Zip:

Your Home Phone Number:

Your Work Phone Number:

Your Other Phone Number:

Your E-Mail Address:

Your Emergency Contact Name:

What is this person’s relationship to you?

Your Emergency Contact Address:

Your Emergency Contact Phone Number:

Your Date of Birth:

Are you currently employed:

Work at Home:

Work Hours per Week:

Your Occupation:

Your Place of Business/School:

If student please list current grade:

Are You Married?

Your Spouse's Name:

Do You have Children:

Your First child’s name:

Child's age:

Live at home?

Your Second child’s name:

Child's age:

Live at home?

Your Third child’s name:

Child's age:

Live at home?

Any Other Children?

Your Weight:

Your Height:

Your Gender:

Your mode of transportation:

Do you own/drive a car?

Do you ride the city bus?

Briefly describe your hobbies and interests:

How do you spend your time on an average day?

Do you travel out-of town more than twice a year?

Please describe means of transport used, and purpose of travel:

Do you attend an exercise program, what type, where?

Do you participate in a physical rehabilitation program, what type, where?

How is your general health?

Do you have mental health issues?

Do you see a therapist/counselor?

If you are a person visiting this site who has information, comments, stories,
opinions or other input on this topic that would be helpful and could be included on the Comments and Input page for
this topic, please email: